Vasopressin during Laparoscopic Myomectomy: Does It Really Extend Its Limits?

STUDY OBJECTIVE: Τo investigate whether the use of vasopressin played an important role in the safe expansion of the indications of laparoscopic myomectomy in our practice. DESIGN: A retrospective comparison of prospectively collected data (Canadian Task Force classification II2). SETTING: A gynecologic endoscopy unit in a tertiary university hospital. PATIENTS: One hundred fifty patients undergoing laparoscopic myomectomy; 50 were treated without the use of any vasoconstrictive agent (group 1), and 100 were treated with intraoperative intramyometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2). INTERVENTIONS: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: We compared the 2 groups in terms of size, number, and type of myomas; estimated blood loss (EBL); procedure length; transfusion rates; laparoconversion rates; and rates of complications. Two cases in group 1 (4%) were laparoconverted versus none (0%) in group 2. Overall, the mean EBL was 321.8 ± 246.0 mL in group 1 compared with 147.8 ± 171.8 mL in group 2, respectively (p <.001). Additionally, EBL was significantly lower in the vasopressin group in all of the study's subgroups of patients stratified according to the size and number of myomas. Procedure length did not differ significantly between the 2 groups (130.8 ± 49.5 vs 115.6 ± 49.4 minutes, p = .078). The risk factors for prolongation of the procedure included size and number of myomas independently of vasopressin. The rates of hypercapnea and subcutaneous emphysema were higher in group 1. The risk factors for hypercapnea and subcutaneous emphysema included the size and intramural position of the largest myoma. Vasopressin was not associated with serious cardiovascular adverse events. CONCLUSIONS: Vasopressin is effective in reducing blood loss during laparoscopic myomectomy. Although experienced surgeons may achieve comparable operation times without vasopressin, even in the most challenging cases, blood loss may still be considerable. The occurrence of hypercapnea is higher in untreated cases and may contribute to laparoconversion.

Can the risks associated with uterine sarcoma morcellation really be prevented? Overview of the role of uterine morcellation in 2018.

OBJECTIVES: The objective of this literature review is to reiterate the epidemiology, clinical signs, and radiological signs that should be consistent with a uterine sarcoma as well as the precautionary pre- and postoperative principles that help prevent morcellation of uterine sarcomas when treating patients with uterine fibroids. METHOD: We conducted this literature review by consulting the Pubmed, Medline, and Cochrane Systematic Review databases up to 28/02/2017 using the following keywords: fibroid, myoma, leiomyoma, sarcoma, leiosarcoma, uterine cancer, myomectomy, hysterectomy, morcellation, and uterine morcellation. We also used the reference lists of the selected articles to find more data on the websites of North-American and European learned societies that specialise in obstetrics and gynaecology. RESULTS: In the case of morcellation of uterine fibroids, the risk of an undiagnosed uterine sarcoma is estimated to be between 1 in 278 to 1 in 1960 women. Preoperative examination, free informed consent following discussion about the risks and complications associated with morcellation, as well as research on the contraindications to the use of morcellation are the crucial points addressed by learned societies. The main solution recommended at present is morcellation confined to a laparoscopic bag. CONCLUSION: There is a risk of morcellating an occult sarcoma when performing a myomectomyor hysterectomy for fibroids. Implementing the use of morcellation containment bags should be the norm. The use of minimally invasive surgery (laparoscopic orvaginal) and the associated benefit-risk ratio compared to a laparotomy should also be discussed with the patient before the operation.

Changes in Myomectomy Practice After the U.S. Food and Drug Administration Safety Communication on Power Morcellation.

OBJECTIVE: To examine the association between the 2014 U.S. Food and Drug Administration (FDA) safety communication on power morcellation and surgical approach and morbidity after myomectomy. METHODS: In this retrospective cohort study, data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database on 3,160 myomectomies between April 2012 and December 2013 (pre-FDA) and 4,378 between April 2014 and December 2015 (post-FDA). Aims were to 1) compare rates of abdominal and laparoscopic myomectomy pre-FDA and post-FDA (primary outcome), 2) directly compare the morbidity of abdominal and laparoscopic myomectomy during each time period (secondary outcome 1), and 3) compare the morbidity after all myomectomies performed pre-FDA and post-FDA (secondary outcome 2). Adjusted means, odds ratios, and rate ratios with 95% confidence intervals were calculated using linear, logistic, and Poisson regression, respectively, adjusting for age, race, ethnicity, body mass index, and myoma burden. RESULTS: Myomectomies performed post-FDA were more likely to be abdominal (60.0%, 95% confidence interval [CI] 58.6-61.5%) than laparoscopic (40.0%, 95% CI 38.5-41.4%) as compared with myomectomies pre-FDA, which were equally divided between surgical approaches (49.1% abdominal, 95% CI 47.4-50.9% compared with 50.9% laparoscopic, 95% CI 49.1-52.6%; P<.001). When directly compared with laparoscopic myomectomy, abdominal myomectomy was associated with longer hospitalizations, higher readmission rates, and greater morbidity both pre-FDA and post-FDA (P<.05, all comparisons). Adjusted models demonstrated shorter operative times post-FDA for all myomectomies (P<.001), although composite morbidity was similar between myomectomies performed pre-FDA and post-FDA (P=.809). CONCLUSIONS: The FDA safety communication on power morcellation was associated with an 11% absolute increase in the use of abdominal myomectomy. Although morbidity is consistently higher after abdominal as compared with laparoscopic myomectomy, the increased reliance on abdominal myomectomy post-FDA did not result in clinically significant changes in morbidity in this cohort.

Cesarean myomectomy in modern obstetrics: More light and fewer shadows.

The study aim was to evaluate management of myomas during cesarean section, the pro and cons and the outcomes of cesarean myomectomy. Moreover, we tried to investigate the long-term outcomes of cesarean myomectomy. The authors conducted a literature review using scientific databases, focusing on the benefits and outcomes of cesarean myomectomy and the recent trends regarding this topic, and identified relevant articles, related references and other papers citing them. Despite the demonstrated advantages of cesarean myomectomy, postponed myomectomy after cesarean section was recommended in some instances. Apart from recent reports on the safety and feasibility of cesarean myomectomy, the current literature also describes serious complications of cesarean myomectomy, including even maternal death. This poses a question about the reported rate of complications: whether it is underestimated in common practice. Although some studies strongly suggest the safety of cesarean myomectomy, data on the long-term outcomes of cesarean myomectomy in women are lacking. The risk-benefit ratio of cesarean myomectomy should be re-evaluated in the new century, given the increasing patient age, incidence of myoma in pregnancy, and the wide use of assisted reproductive techniques.

Safety and efficacy of the minilaparotomy for myomectomy: a systematic review and meta-analysis of randomized and non-randomized controlled trials.

Myomectomy is the most frequent reproductive surgery to preserve, improve fertility, or both. The present study was designed to assess the safety and efficacy of minilaparotomy for myomectomy through a systematic review of randomized and non-randomized controlled trials with a meta-analysis. All available studies comparing minilaparotomy myomectomy with laparotomy, other minimally invasive surgeries, or both, were included. Available surgical and reproductive data were extrapolated, and a qualitative and quantitative analysis was carried out. Fourteen studies were included in the final analysis for an overall sample of 2151 patients. A total of 1139 patients were treated with minilaparotomy, whereas 239 and 773 patients were treated, respectively, with the laparotomy or laparoscopy. Only two studies comparing minilaparotomy with laparoscopy assessed the reproductive outcomes, and their data synthesis did not demonstrate significant difference between the two surgical techniques. Specific surgical end-points differed significantly between minilaparotomy and laparotomy or laparoscopy, even if those differences were not clinically relevant. In conclusion, current data do not permit a definite conclusion to be drawn. Further studies are needed to clarify the risk-benefit ratio of the minilaparotomy compared with the other minimally invasive surgical procedures for myomectomy to provide clinical recommendations with strong scientific evidence.